Dr Badami on a Case Study Illustrating Key Decisions for First-Line Metastatic RCC

Ami Umesh Badami, MD, hematologist/oncologist, Loyola University Medical Center, discusses a case study highlighting the diagnostic and therapeutic journey of a patient with metastatic clear cell renal cell carcinoma (RCC), illustrating key decision points in the management of advanced disease.

The patient initially presented with RCC and underwent nephrectomy, Badami explains. During routine surveillance, scans identified 2 lung nodules were identified, and they were retrospectively identified on earlier scans. This led to a discussion about how to approach treatment for a patient with oligometastatic disease or low-volume, indolent disease, Badami says.

She continues by noting that this particular patient's preference with treatment was to avoid unnecessary toxicity. Given that preference, treatment options focused on either local radiation therapy for the lung nodules or observation. Ultimately, the decision was made to proceed with active surveillance, Badami notes.

However, upon disease progression, first-line systemic treatment options were revisited, she continues. The first-line treatment setting for metastatic clear cell RCC has shifted significantly in recent years with immunotherapy-based combinations taking precedence, and these options were explored, Badami notes. These combinations can included dual immune checkpoint inhibitors with nivolumab (Opdivo) plus ipilimumab (Yervoy), or an immune checkpoint inhibitor in combination with a TKI, such as nivolumab plus cabozantinib (Cabometyx), pembrolizumab (Keytruda) plus lenvatinib (Lenvima), or atezolizumab (Tecentriq) plus cabozantinib.

Treatment selection often requires balancing efficacy with tolerability, Badami emphasizes. In patients with limited disease burden, such as those with oligometastatic RCC, a more conservative approach may be appropriate initially to limit adverse effects. For those with symptomatic progression, more aggressive systemic options are warranted to achieve better disease control, she concludes.